ECTOPIC PREGNANCIES IN TWO CONSECUTIVE

MENSTRUAL CYCLES CASE REPORT

AKRAM ABD ELGHANY

MD.OBS.&GYN.

ALAZHAR UNIVERSITY EGYPT

Consultant obs.& gyn.

CASE REPORTA 33-year-multipara presented with

missed period with IUCD. regular menstrual cycle (28-30 days).

Her last menstruation had been from March 27 ,2010 for 4 days.

Urinary pregnancy test was positive on 1 May 2010 repeated many times over 2weeks.

On MAY 18, 2010 ,She presented with lower abdominal pain and irregular vaginal bleeding for 2 weeks.

positive pregnancy test. vital parameters were normal. abdominal examination revealed rigidity suprapubic tenderness and rebound tenderness .

Pelvic examination tender fornices and tender cervical motion.

Transvaginal ultrasound (TVS) showed

AVF bulky empty uterus. endometrium trilamner 6mm. LT. complex heterogenous mass 50x40 mm beside left ovary.

RT. adnexa is free. moderate amount of fluid in the

pouch of Douglas.

The patient was counselled concerning the possibility of an ectopic pregnancy and informed consent for

laparoscopic exploration,with the possible need for salpingostomy or salpingectomy was obtained.

At laparoscopy pelvic collection of blood. LT .tube ruptured in mesosalpinex forming a hemorrhagic mass 5x4cm .

Blood escape from LT.fimberia. The RT. adnexa was free . The left mesosalpinex was then found to contain a mass 5cm consistent with an ectopic pregnancy.

salpingectomy of the LT. tube produced products resembling hemorrhagic tissue typically found with ectopic pregnancies.

There were no complications from the surgery and the patient recovered well.

The products of conception and the LT. tube were removed through a 10 mm RT. Trocar.

She visited my clinic 4 times thereafter with no post operative complains except umbilical wound infection.

On 20 June 2010 she visited my clinic with 5 weeks amenorrhea and positive home pregnancy test.

there were no complain. general ,abdominal and pelvic examination were normal.

TVS diagnosed RT. Adnexal mass 20 mm x 15 mm.

gestational sac 8mm. yolk sac is present. no embryonic echo. minimal fluid in DP. LT.adnexa is free.

serum B,hCG was 15,000 IU/L. RT. recent new 5 weeks undisturbed ectopic pregnancy was diagnosed.

the patient refused conservative management to save the RT. Tube.

RT. salpingectomy was done through laparotomy in another clinic on 22 June 2010.

No attemps were made to save the last tube.

No blood transfusion.

COMMENT This seems to be a rare, atypical case of ectopic pregnancies in two consecutive menstrual cycles.

There is a great rarity of this event.

With the incidence of ectopic pregnancy increasing, bizarre cases (for example, heterotopic, bilateral or consecutive) will be seen more often. Irvine,etal.1999

IRVINE,ETAL. J R SOC MED 1999 Reported the first case of ectopic

pregnanccies in two consecutive menstrual cycles.

A 28-year-old multigravid woman reported six weeks of amenorrhoea and two days of abdominal pain and vaginal bleeding.

On examination she was haemodynamically stable.

the abdomen was tender, and the uterus was bulky with tenderness in the left fornix.

A urinary pregnancy test was positive.

At laparotomy a small leaking left distal ectopic pregnancy was seen and a left partial salpingectomy was performed.

the right adnexa was noted to be normal.

She recovered uneventfully and was discharged home on the fifth postoperative day.

At her eight-week follow-up visit she complained of right-sided abdominal pain.

on vaginal examination she was tender in the right adnexa.

On admission the differential diagnosis was judged to be pelvic inflammatory disease, urinary tract infection or appendicitis.

A transabdominal scan showed a normal-sized uterus with a 2 cm ill-defined echo-poor area by the right ovary, thought to be a small collection of fluid.

She was afebrile and clinically stable.

Treatment was started with intravenous erythromycin 200mg three times daily and blood samples were taken six days apart for measurement of beta human chorionic gonadotropin, which was 120 U/L rising to 170 U/L.

Her abdominal pain settled and she was clinically well but, in the absence of a definitive diagnosis.

laparoscopy was done on day seven.

She had a haemoperitoneum of 200 mL and a right distal leaking ectopic pregnancy.

A right partial salpingectomy was performed.

Histological examination of both fallopian tubes revealed chorionic villi, confirming the ectopic pregnancies.

WALTER,ETAL. AUST N Z J OBSTET GYNAECOL 2004 reported a case of bilateral chronic and acute tubal pregnancies following failed treatment with methotrexate for a previous ectopic pregnancy.

URMAN AND MCCOMB ACTA EUR FERTIL 1989

Reported evidence in support of superfetation in a patient who had an ongoing ectopic pregnancy. The patient had a documented rise in mid-cycle basal body temperature, suggesting ovulation occurred while she carried a tubal pregnancy.

KOBAYISHI, ET AL. HUM REPROD 1996 encountered a unique case of combined pregnancy in which an intrauterine pregnancy was established following a spontaneous ovulation occurring whilst the woman had another ectopic pregnancy.

KOBAYISHI,ETAL CASE REPORT S,b,HCG 1024 IU/L . Pelvic examination and ultrasonography indicated an extrauterine pregnancy, which was confirmed by laparotomy and histological identification of trophoblast cells.

HCG concentration markedly decreased after the operation.

The HCG level increased again on the fifth postoperative day,and

a gestational sac (11 mm) was identified in the uterine cavity on the 11th post-operative day, indicating that this intrauterine pregnancy was established following spontaneous ovulation which occurred before the removal of the extrauterine pregnancy.

This case indicates that a combined pregnancy can occur not only after simultaneous multiple ovulations but also after the separate spontaneous ovulations.

FOX,ETAL.OBSTET GYNECOL 1963Reported Bilateral tubal pregnancies in the absence of preceding induction of ovulation are an extremely unusual occurrence and are thought to represent the rarest form of extrauterine pregnancy. More common are twin pregnancies in the same tube and heterotopic pregnancies.

JAMES,ETAL.JOGC 2008 A 25-year-old gravida 3, para 0 woman

was an approximate gestational age of 9 weeks and 2 days.

Presented with vaginal bleeding and intermittent lower abdominal cramping.

The patient was hemodynamically stable.

The initial level of serum hCG was 24,242 IU/L.

A transvaginal pelvic ultrasound examination revealed an empty uterus with a right adnexal mass measuring 4.3 x 2.3 cm.

bilateral tubal pregnancies diagnosed intraoperatively.

The pathology report confirmed the diagnosis of spontaneous bilateral tubal pregnancies,

the tissue removed from the right tube showing blood clot admixed with chorionic villi.

The tissue obtained from the left tube showed multiple fragments of fetal tissue, including the vertebral column, neurological structures, liver, intestine, umbilical cord, and chorionic villi.

SINDOS, ETAL. AM J OBSTET GYNECO 2003 Reported a 31-year-old woman with a

positive pregnancy test. a transvaginal ultrasound scan result

that was suggestive of a right tubal ectopic pregnancy.

a laparoscopy, showed bilateral hematosalpinx.

In the presence of active bleeding and deteriorating hemodynamic status of the patient, a minilaparotomy was performed that revealed a right-sided hematosalpinx and a left-sided ectopic gestation.

ALSAMMOUA,ETAL.SMJ 2008 described a unique case of concurrent chronic and acute ectopic pregnancies in an ipsilateral tube.

A 33-year-old woman presented with symptoms suggestive of miscarriage that resolved on conservative management, resulting to normal ßhCG level.

CHRONIC ECTOPIC she was readmitted 5 weeks

later with vaginal spotting, right iliac fossa pain .

TVS revealed an empty uterus, no signs of retained products of conception and a small 1.9x1.6x1.3cm mass medial to right ovary. ßhCG was 34 U/L.

A diagnosis of pregnancy of unknown location was made and she was managed conservatively.

ACUTE ECTOPIC Four weeks later the patient presented

once again with vaginal bleeding and a positive pregnancy test.

TVS showed a right adnexal mass (1.3x1.5x1.6 cm) and some free fluid in pelvis.

ßhCG was highly elevated at 9661 U/L. A diagnosis of ectopic pregnancy was

made and the patient underwent laparoscopic salpingectomy.

Histopathological examination showed two ectopic pregnancies within the same tube; an older (chronic) ectopic positioned within proximal end of the tube and a more recent acute one at the distal end. 

 

Histopathological examination of the removed tube showed “two separate lesions manifesting two ectopic pregnancies; an older (chronic) one positioned proximally and more recent one at the distal end.

Sections of the 6 mm lesion towards the uterine proximal end of the fallopian tube showed characteristic features of chronic ectopic pregnancy: a fibrinous nodule with evidence of fresh and old haemorrhage. Within this; the "ghost" outlines of a few necrotic chorionic villi were identified” .

The other lesion noted at the distal end of the fallopian tube close to the fimbria was a viable decidua, and unvascularised small chorionic villi .

THREE IPSILATERAL SPONTANEOUS ECTOPIC PREGNANCIES.

Milingos ,etal. reported the case of a patient who had three consecutive ectopic pregnancies on the ipsilateral side after natural conception and was treated surgically in each case with partial salpingectomy, removal of tubal stump, and resection of the uterine cornua, respectively. The contralateral normal tube was resected at the time of last operation.

Obstet Gynecol. 2008

POST ECTOPIC OVULATION Clinically, ovulation has been reported to occur 2 weeks after

artificial abortion of intrauterine pregnancy .

Boyd and Holmstrom,1972

operation for ectopic pregnancy .

Spirtos et al,1987

50% demonstrated ovulation before day 14 after mangement of chronic ectopic pregnancy. (serum progesterone at least 3 ng/mL on day21)

the onset of ovulation is missed in approximately three-quarters of cases and hence the possibility of further pregnancy.

contraception should be introduced immediately after surgery, if further pregnancy is unwanted or contraindicated.

Spirtos,et al.Obstet Gynecol 1987

BAHAMONDES ET AL. (1995)

reported that the administration of exogenous HCG for ovulation induction or luteal support lowered the FSH in the late luteal phase, and increased the size of persistent follicles in the late luteal phase and the follicular phase of the next cycle.

They speculated that the trigger of the second ovulation was endogenous HCG.

HUMAN CHORIONIC GONADOTROPIN  There is a wide range in the

normal hCG level at each week of pregnancy

5,000 to 150,000 IU/L. Silva et al,

2006 . Quantitative tests are not useful

for estimating gestational age because of the wide range in hCG levels at any given point in pregnancy .

Seeber, Obstet Gynecol 2006.

The hCG concentration rises at a much slower rate in most, but not all, ectopic and nonviable intrauterine pregnancies.

only 21 percent of ectopic pregnancies were associated with hCG levels that followed the minimum doubling time of a viable intrauterine pregnancy (defined in this series as ≥ 53 percent increase over two days). Silva et al, 2006.

The serum B,HCG of ectopic pregnancy may be very high as in viable undisturbed ectopic , twin ectopic , vesicular mole with ectopic and bilateral tubal ectopic.

A falling hCG concentration is most consistent with a failed pregnancy eg,

arrested pregnancy. anembryonic pregnancy. tubal abortion, spontaneously

resolving ectopic pregnancy.

complete or incomplete abortion.

TRANSVAGINAL ULTRASOUND 

The earliest sonographic sign of an intrauterine pregnancy is the presence of

A true gestational sac, which has double echogenic rings surrounding the sac. Bradley, Radiology 1982.

TRANSVAGINAL ULTRASOUND the gestational sac is usually visible at 4.5 to 5 weeks of gestation.

an embryo with cardiac activity is first detected at 5.5 to 6 weeks.

Pseudosacs are often found in association with ectopic pregnancy. They tend to be located in the middle of the uterine cavity rather than embedded in the decidua, and conform to contour of the cavity.

DIAGNOSIS OF EXTRAUTERINE PREGNANCY Visualization of an extrauterine

gestational sac containing a yolk sac or embryo is diagnostic of ectopic pregnancy, but this combination of findings is detected in only a small proportion of cases 20% .

in expert ultrasound units, abnormalities suggestive of the diagnosis will be identified in 90 percent of ectopic pregnancies .

Condous,etal. Hum Reprod 2005.

TVS A complex adnexal mass in the presence of a positive pregnancy test and empty uterus is highly suggestive of an extrauterine gestation and is the most common sonographic abnormality.

TVS IN THE DIAGNOSIS OF ECTOPIC PREGNANCY the sensitivity of 73.9 percent (95% CI 65.1– 81.6),

a specificity of 99.9 percent (95% CI 99.8– 100),

a positive predictive value of 96.7 percent (95% CI 90.7– 99.3),

a negative predictive value of 99.4 percent (95% CI: 99.2– 99.6).

Kirk,etal. Hum Reprod 2007.

HCG ABOVE THE DISCRIMINATORY ZONE  TVS does not reveal an intrauterine pregnancy and shows a complex adnexal mass, an extrauterine pregnancy is almost certain.

The diagnosis of ectopic pregnancy is less certain if no complex adnexal mass can be visualized.

repeat the TVS examination and hCG concentration two days later.

If an intrauterine pregnancy is still not observed on TVS, then the pregnancy is abnormal.

HCG BELOW THE DISCRIMINATORY ZONE A serum hCG concentration less than 1500 IU/L should be followed by repetition of hCG in three days to follow the rate of rise.

HCG concentrations usually double every 1.4 to two days until six to seven weeks of gestation in viable intrauterine pregnancies (and in some ectopic gestations).

A normally rising hCG concentration should be evaluated with TVS when the hCG reaches the discriminatory zone. At that time, an intrauterine pregnancy or an ectopic pregnancy can be diagnosed.

If the hCG concentration does not double over 72 hours then the pregnancy is abnormal (an ectopic gestation or failed intrauterine pregnancy).

The clinician can be reasonably certain that a normal intrauterine pregnancy is not present.

If an adnexal mass is visualized on TVS, then medical or surgical treatment is administered for a presumed ectopic pregnancy.

If an adnexal mass is not visualized, some clinicians administer methotrexate and others perform curettage to determine the type of nonviable pregnancy and thereby avoid medical therapy of nonviable intrauterine pregnancies .

Seeber,etal.Obstet Gynecol 2006.

HIGH RISK FACTORS FOR ECTOPIC Previous ectopic pregnancy.recurrence is 15%

Tubal pathology and surgery. chronic salpingitis, is observed in up to 90 percent of ectopic pregnancies.

Intrauterine contraception

CHRONIC ECTOPIC PREGNANCY is a problematic diagnosis. The clinical presentation can be

mild, with absent or subtle symptoms.

The high incidence of negative pregnancy tests or very low ßhCG, the poor specificity of sonographic patterns can be misleading.

The correct diagnosis can only be established at surgery or following histopathological examination of the resected specimen.

The presentation of chronic ectopic pregnancy as an inflammatory mass can cause problems in differential diagnosis.

The involution of the trophoblast may allow the menstrual cycles to re-establish and the convoluted, blood- filled tube often involving the ipsilateral ovary may simulate tumour or an endometriotic mass

The classic symptoms of ectopic pregnancy are :

Abdominal pain 99%. Amenorrhea 74%. Vaginal bleeding 54%. these symptoms are not diagnostic of ectopic pregnancy; they are the same as those associated with threatened abortion, which is far more common.

MANAGEMENT OF ECTOPIC PREGNANCY dramatically moved away from a

primarily surgical approach . Yao,etal.Fertil Steril 1997.

Currently, most women with unruptured ectopic pregnancies are treated with methotrexate.

some women undergo surgical therapy by choice or by necessity, if they are not good candidates for medical therapy.

The extent of surgical management would depend on the size of the mass, involvement of adjacent organs and the reproductive history of the patient. This might vary from conservative surgical excision of the mass to salpingo-oophorectomy or even more extensive surgery.

Failure to diagnose ectopic pregnancy before tubal rupture limits the treatment options and increases maternal morbidity and mortality.

four factors that increased the risk of rupture when an ectopic pregnancy was suspected:

(1) never having used contraception, (2) history of tubal damage and

infertility, (3) induction of ovulation, and (4) high level of HCG (at least 10,000

IU/L) .

EXPECTANT MANAGEMENT is not recommended. It is possible that some ectopics will

resolve spontaneously. The initial titer of hCG and the trend on

serial monitoring are both predictors of success for expectant management.

The higher the initial concentration, the more likely it is that expectant treatment will fail.

If the initial concentration is <1000 mIU/mL, expectant management can be successful in 88% of cases

INDICATIONS FOR SURGICAL TREATMENT Hemodynamic instability. Impending rupture of ectopic . mass Contraindications to use of

methotrexate. Coexisting intrauterine pregnancy . Not able or willing to comply with medical

therapy posttreatment follow-up. Lack of timely access to a medical institution

for management of tubal rupture . Desire for permanent contraception . Known tubal disease with planned in vitro

fertilization for future pregnancy. Failed medical therapy

COMPLEX ADNEXAL MASS In hemodynamically stable women, surgical intervention should only be considered if a transvaginal ultrasound examination (TVS) clearly shows a tubal ectopic pregnancy or an adnexal mass suggestive of ectopic pregnancy.

If no abnormality is imaged sonographically, there is a high probability that an ectopic pregnancy will not be visualized or palpated at surgery.

these women should be managed conservatively with either medical therapy or expectant management.

A repeat ultrasound examination after a few days may visualize an abnormality, thus enabling a surgical procedure, if this option is desired.

THE ADVANTAGES OF SURGICAL TREATMENT less time for resolution of the ectopic pregnancy.

avoidance of the need for prolonged monitoring.

SALPINGOSTOMY VERSUS SALPINGECTOMY Operative morbidity is similar for both

procedures. Salpingectomy does not appear to

compromise the rate of subsequent intrauterine pregnancy in women whose contralateral fallopian tube appears to be normal and avoids the complication of persistent or recurrent ectopic pregnancy in the same tube.

reproductive outcome reflect tubal status at surgery, rather than the choice of surgical procedure. Dubuisson, et al.Hum Reprod 1996.

SALPINGECTOMY In these situations, there is a low

probability of future normal tubal function and the risk of persistent or recurrent tubal problems is high.

We perform salpingectomy, instead of salpingostomy in the following situations:

Uncontrolled bleeding from the implantation site.

Recurrent ectopic pregnancy in the same tube.

Severely damaged tube. Large tubal pregnancy (ie, greater than 5

cm). Women who have completed childbearing.

SALPINGOSTOMY hemodynamically stable.

reasonable probability of future normal tubal function in the affected tube.

LAPAROSCOPY VERSUS LAPAROTOMY Laparoscopic surgery is the standard

surgical approach for ectopic pregnancy.

Most ectopic pregnancies, even in the presence of hemoperitoneum, heterotopic pregnancy, and interstitial pregnancy, can be treated by a laparoscopic procedure.

However, the surgical approach depends upon the experience and judgment of the surgeon and the anesthetist, and the clinical status of the patient.

PERSISTENT ECTOPIC PREGNANCY

The incidence 4 to 15 percent. higher after laparoscopic salpingostomy

than after open procedures.

The serum beta-hCG concentration on the first postoperative day generally declined by more than 50 percent of the preoperative value .

In series of 147 women treated conservatively for ectopic pregnancy, there were no cases of persistent ectopic pregnancy when the postoperative beta-hCG on day 1 fell by more than 76 percent .

Spandorfer, etal. Fertil Steril 1997.

Transvaginal ultrasound examination of the pelvis and measurement of serum beta-hCG concentration are then performed weekly until the level is undetectable.

Alternatively, prophylactic treatment with one dose of methotrexate can be given after all salpingostomies.

Gracia, etal. Fertil Steril 2001.

FUTURE PREGNANCY

 Ectopic implantation usually occurs because clinical or subclinical salpingitis has caused anatomic and functional changes in the fallopian tubes.

These changes are typically bilateral and permanent.

it is not surprising that ectopic pregnancy often leads to recurrent ectopic pregnancy and infertility.

In women with a history of ectopic pregnancy, 38 to 89 percent will achieve a subsequent intrauterine gestation .

Recurrent ectopic pregnancy is 15 percent (range 4 to 28 percent).

Farquhar, Lancet 2005.

The recurrence risk rises to 30 percent following two ectopic pregnancies.

Tulandi,etal.Fertil Steril 1988.

RECURRENCE

Recurrence of an ectopic pregnancy seems to be similar for all modes of treatment and is variously quoted as up to 26%, with averages around 6-12%.

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